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A neonate delivered at 37 weeks' gestation has been admitted to the neonatal intensive care unit for respiratory distress. The physician has ordered an I.V. for fluid support. To increase safety prior to hanging new I.V. fluids for a neonate, the nurse should:
- A. Check the neonate's weight.
- B. Determine if the neonate has adequate urine output.
- C. Determine the neonate's glucose level.
- D. Double-check the fluids and physician's order with another nurse.
Correct Answer: D
Rationale: Double-checking the fluids and physician's order with another nurse ensures accuracy and safety, reducing the risk of medication or fluid errors.
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A laboring client at -2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The nurse should first:
- A. Place gentle pressure upward on the fetal head.
- B. Place the cord back into the vagina to keep it moist.
- C. Begin oxygen by face mask at 8 to 10 L/min.
- D. Turn the client on her left side.
Correct Answer: A
Rationale: Gentle pressure prevents cord compression.
During an assessment of a neonate born at 33 weeks' gestation, a nurse finds and reports a heart murmur. The neonate is diagnosed with patent ductus arteriosus, for which the neonate received indomethacin. An expected outcome after the administration of indomethacin to a neonate with patent ductus arteriosus is:
- A. Closure of a patent ductus arteriosus.
- B. Decreased bleeding time.
- C. Increased gastrointestinal function.
- D. Increased renal output.
Correct Answer: A
Rationale: Indomethacin promotes closure of the patent ductus arteriosus by inhibiting prostaglandin synthesis.
A nurse and a nursing assistant are caring for clients in a labor and delivery unit. Which task should the registered nurse assign to the nursing assistant?
- A. Perform a fundal check on a 2-day postpartum client.
- B. Remove a fetal monitor and assist a client to the bathroom.
- C. Give ibuprofen 800 mg by mouth to a newly delivered client.
- D. Teach a new mother how to bottle-feed her infant.
Correct Answer: B
Rationale: A nursing assistant can assist with mobility tasks like removing a fetal monitor and helping a client to the bathroom. Fundal checks, medication administration, and teaching require RN skills.
A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
- A. Metabolic alkalosis.
- B. Metabolic acidosis.
- C. Respiratory alkalosis.
- D. Respiratory acidosis.
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.
After the nurse teaches a primiparous client planning to return to work in 6 weeks about storing breast milk, which of the following client statements indicates the need for further teaching?
- A. I can let the milk sit out in a bottle for up to 10 hours.
- B. I'll be sure to label the milk with the date, time, and amount.
- C. I can store the milk for 3 days in the refrigerator.
- D. I can keep the milk in a deep-freeze in clean glass bottles for up to 1 year.
Correct Answer: A
Rationale: Breast milk should not be left out for more than 4-6 hours; 10 hours risks spoilage.